Can low cortisol cause sexual dysfunction?

Low Cortisol and Sexual Dysfunction

Yes, low cortisol (adrenal insufficiency) can directly cause sexual dysfunction in both men and women, and this dysfunction is often reversible with appropriate glucocorticoid replacement therapy.

Evidence for Sexual Dysfunction in Adrenal Insufficiency

Prevalence and Clinical Presentation

• Sexual dysfunction is highly prevalent in patients with adrenal insufficiency, affecting 41% of women and 59% of men in a recent multicenter trial 1
• In women with primary adrenal insufficiency, 68% experience sexual symptoms (measured by FSFI-6 score <19), compared to only 9% of healthy controls 2
• Sexual desire appears to be the most severely impaired domain in women with adrenal insufficiency, with significant deficits also noted in arousal, lubrication, and overall sexual satisfaction 2

Mechanism and Reversibility

• In men with newly diagnosed autoimmune Addison's disease, all sexual function parameters—erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction—were significantly impaired at baseline and improved substantially after 2 months of glucocorticoid and mineralocorticoid replacement therapy 3
• The improvement in erectile function correlated significantly with increases in serum cortisol, urinary free cortisol, and normalization of plasma renin activity, suggesting that both cortisol and aldosterone deficiency contribute to sexual dysfunction 3
• In women with primary adrenal insufficiency, sexual function scores correlate directly with serum cortisol levels (r = 0.55; p = 0.035), indicating that inadequate cortisol replacement may perpetuate sexual symptoms 2

Distinguishing Adrenal Insufficiency from Other Causes

When to Suspect Adrenal Insufficiency

The ASCO guidelines emphasize that DHEA replacement is controversial but deficiency can be tested and replacement considered in women with low libido and/or energy who are judged to be otherwise well replaced on standard glucocorticoid and mineralocorticoid therapy 4

However, before attributing sexual dysfunction solely to DHEA deficiency or other causes:

• Evaluate for classic features of adrenal insufficiency: fatigue, weight loss, hypotension, nausea, salt craving (in primary AI), and hyperpigmentation (in primary AI) 5
• Obtain morning (8 AM) cortisol and ACTH levels to screen for adrenal insufficiency 5
• Morning cortisol <250 nmol/L (<9 μg/dL) with elevated ACTH is diagnostic of primary adrenal insufficiency; low cortisol with low or inappropriately normal ACTH suggests secondary adrenal insufficiency 5
• If morning cortisol is indeterminate (140-550 nmol/L or 5-20 μg/dL), perform cosyntropin stimulation testing with 0.25 mg IV/IM; peak cortisol <500 nmol/L (<18 μg/dL) at 30 or 60 minutes confirms adrenal insufficiency 5

Important Caveats

• Sexual dysfunction in adrenal insufficiency correlates more strongly with quality of life and fatigue scores than with hormone levels alone 1, suggesting that the mechanism is multifactorial and includes both direct hormonal effects and indirect effects mediated by overall well-being
• In women with low sexual desire but without other features of adrenal insufficiency, lower morning cortisol and DHEA levels, flatter diurnal cortisol slope, and blunted cortisol awakening response have been documented 6, indicating that HPA axis dysregulation—rather than frank adrenal insufficiency—may contribute to sexual dysfunction in some cases
• Fibromyalgia and chronic fatigue should not be diagnosed until adrenal insufficiency is definitively excluded, particularly when patients have unexplained hypotension, collapse, or electrolyte abnormalities 7

Management Approach

If Adrenal Insufficiency is Confirmed

• Initiate glucocorticoid replacement with hydrocortisone 15-25 mg daily in divided doses (typically 10 mg at 7 AM, 5 mg at noon, 2.5-5 mg at 4 PM) to recreate the diurnal cortisol rhythm 4, 5
• For primary adrenal insufficiency, add fludrocortisone 50-200 µg daily for mineralocorticoid replacement 5
• Reassess sexual function after 2-3 months of adequate replacement therapy, as sexual dysfunction is often reversible once cortisol and aldosterone deficiency are corrected 3
• If sexual dysfunction persists despite adequate glucocorticoid and mineralocorticoid replacement, consider DHEA replacement (particularly in women with low libido and energy), though this remains controversial 4

Critical Pitfalls to Avoid

• Never delay treatment of suspected acute adrenal crisis for diagnostic testing; if a patient presents with unexplained hypotension, collapse, or severe vomiting, administer 100 mg IV hydrocortisone immediately plus 0.9% saline infusion at 1 L/hour 5
• Do not attribute sexual dysfunction solely to psychological or functional disorders without first excluding adrenal insufficiency, especially when other suggestive features are present 7
• Recognize that switching to dual-release hydrocortisone formulations does not directly improve sexual function, though indirect benefits mediated by quality-of-life improvement cannot be excluded 1